An Inclusive Practice

As the pediatric dentist walked her 4-year-old patient back to the waiting room, she inquired, “Is your mommy or daddy here?” The child, who had two mommies, burst into tears. The dentist, a lesbian, felt awful.

“Never, ever, ever make assumptions,” said Jeffrey Greenberg, D12, who discussed caring for lesbian, gay, bisexual or transgendered (LGBT) patients for the School of Dental Medicine’s Adapting to Diversity in Dentistry lecture series.

Why should dentists care about a patient’s sexual orientation or gender identity? For the same reason dentists need to ask about smoking, drinking and other personal habits, said Greenberg, who is gay and works in a private practice in Boston. “There are certain aspects to patient behavior that directly affect oral health and overall health.”

Members of the LGBT community are at higher risk for certain conditions that directly impact their health, said Greenberg, citing data from the Centers for Disease Control and Prevention. These include eating disorders, substance abuse, domestic violence and homelessness. Additionally, people who are transitioning from one gender to the other may be taking sex hormones, which are known to affect periodontal health.

A dentist who knows that a patient is gay or transgendered—and can understand and empathize with that person—is better equipped to look out for these kinds of health issues. “It’s a flag you should have in the back of your mind,” said Greenberg. “Before you can work on any patient, you have to know where that person is coming from as a whole.”

Sometimes that means having uncomfortable conversations. “Your role is to bring up anything that you can see that affects their oral health,” he said. “You have to give people the option to be honest. They have to choose whether or not to be honest with you, but at least you asked.” Greenberg recommends being direct, maintaining eye contact and minimizing the number of people in the room. If dentists remember these issues have clinical relevance, they’ll feel more confident asking about them, he said.

Fear Factor

Many LGBT patients live in fear of negative reactions to their orientation or gender identity. That alone can be a barrier to this patient population seeking dental care. Greenberg reminded the audience that there is even more at stake, displaying a map of the states where it is legal to fire people for being gay or transgendered. In 29 states, gay, lesbian or bisexual employees have no legal protection, and transgendered people lack protection in 33 states.

“People can lose their jobs if they are even suspected of being gay or lesbian,” he said. “The job-loss issue directly relates to dental benefits.”

In states where gay marriage isn’t legal, health and dental benefits may not be offered to same-sex partners. Many insurance plans exclude transgendered individuals. That’s why these patients may be especially reluctant to reveal their sexual preference or gender identity to their dentists.

“Most patients won’t sit down and say, ‘Oh, by the way, I’m gay.’ The fear of outing is huge and tricky. Some people also fear becoming a victim of hate crimes,” said Greenberg.

What’s a dentist to do, then? Greenberg said a few simple changes can create an inclusive atmosphere for your LGBT patients.

“The big one here is to convert your usage of gender-specific nouns and pronouns. Don’t say boyfriend/girlfriend or husband/wife,” he said, recounting an anecdote about a male patient whose dentist spotted his wedding ring and asked about the patient’s wife. The patient was legally married to another man.

“It’s such a small mistake; it may seem so benign,” said Greenberg. “But what happens with the patients is that they shut down, and they’ll never go back to that office.”

Involve the Whole Office

It’s not just dentists who need to be mindful. Hygienists, dental assistants and receptionists—the whole office staff—should be trained to use neutral language and maintain patients’ privacy. “Unfortunately, discrimination can happen before you ever see the patient,” said Greenberg.

For example, consider the standard patient-intake form. If there are only two checkboxes, one for male, one for female, “you’ve already discriminated against transgendered people. You’ve said your office doesn’t see ‘others,’ ” he said.

Not yet two years out of dental school, Greenberg said he grew up in the profession: both his parents are dentists, and 16 members of his extended family are in the field. Greenberg was invited to speak on caring for the LGBT population by Kanchan Ganda, a professor in the department of diagnosis and health promotion, who mentored him as a student when he conducted research analyzing the effects of mental illness and low socioeconomic status on oral health, with the aim of improving outcomes in the dental school setting. The pair has since collaborated to develop a lecture and speaker series to teach third-year dental students about providing care to the LGBT population.

“These are topics very close to my heart. Helping us understand the needs of the LGBT and underserved populations helps us grow as providers,” Ganda said. “A teacher can always learn from a student, and I learned so much from Jeff. I am forever grateful to be sensitized about the needs of the LGBT population,” she said.